Systematic Psychiatric Evaluation

2013Yuma Yokoi, MD

Conflict of Interest

• A member of Japanese translation team of “Systematic Psychiatric Evaluation”

Why diagnose?

1) Usefulness for treatment planning2) Implications for prognosis3) Contribution to protecting consumers of

mental services4) Value in enabling the therapist to convey

empathy5) Role in reducing the probability that certain

easily frightened people will flee from treatment

McWilliams N (2011)

Has psych diagnosis labeled rather than enabled patients?

Pros of diagnosis• Provides boundary and

enables psychiatrists maintaining its integrity

• Framework to disseminate the knowledge gained

Cons of diagnosis• Overmedicalization• Diagnostic overshadowing

(physical symptoms misattributed to mental illness)

• Ticket to long-term institutionalization

• Patients may be deprived of their legal capacity

Callard F et al. BMJ 2013;347:f4312

Three questions for psychiatrists

1. What is psychiatry’s domain of study?2. How can one make reliable and valid

observation in that domain?3. How is the domain generated by the brain?

How diagnose?

Individual

Biological + Psychological + Social = Biopsychosocial

PsychodynamicDSM

ICD

Descriptive

(Operational)

Descriptive vs. operational in Japan

Descriptive Operational p

Alzheimer’s disease 16 (9.9%) 15 (9.1%) n.p.

Schizophrenia 79 (49.1%) 39 (23.8%) <0.001

Personality disorder 61 (37.9%) 42 (25.6%) <0.01

Social anxiety disorder 4 (2.8%) 16 (9.8%) <0.01

Egawa J et al. (2010)

Momentary assessment with the Experience Sampling Method

van Os J et al. (2013)

Contextual precision diagnosis

van Os J et al. (2013)

The Perspectives of Psychiatry

Systematic Psychiatric Evaluation

1. A detailed history2. A history obtained and presented in a specific

sequence3. A history obtained from multiple sources

(including collateral informants)4. A systematic mental state exam5. A careful differentiation between

observations and interpretations

Mental state exam

1. Appearance/behavior2. Speech

1. Volume2. Rate3. Rhythm4. Fluidity5. Spontaneity6. Latency7. Thought disorder

3. Mood and affect (observed and reported)

1. Stability, reactivity, appropriateness

2. Vital sense3. Self-attitude4. Thoughts of death,

suicide, homicide

Mental state exam (ctnd.)

4. Abnormal Perceptions1. Illusions2. Hallucinations

5. Content of Thought1. Delusions2. Obsessions3. Compulsions4. Phobias

6. Insight and Judgment

7. Cognition1. Level of consciousness2. Orientation3. Memory4. Praxis5. Language6. Abstraction7. Fund of knowledge8. Attention9. Calculation10. Executive function

Perspectives of PsychiatryPerspective Triad What a patient…

Disease Clinical Syndrome Pathological Process Etiology

Has

Dimensional Potentials Provocations Responses

Is

Behavior

Does

Life story Setting Sequence Outcome Encounters

PhysiologicalDrive

ConditionedLearning

Choice

The Life-story perspective:

1. Is a personal perspective2. Is based on the logic of narrative with its triad

of setting, sequence, and outcome, which is produced meaningfully and understandably

3. It applies to psychiatric conditions that arise from something an individual has encountered

4. It suggests rescripting as the treatment goal

The life-story perspective

A recently widowed patient may seek treatment for feelings of loneliness and sadness following the loss of her husband. Her clinician understands her symptoms as arising from loss and uses psychotherapy to help the patient “rescript” her life story and regain a feeling of mastery over her circumstances. Type of story told may be less important than the therapeutic relationship and other factors.

Peters ME et al. 2011

Life story

Pros• Vivid way to capture a part

of reality• Best way to enhance our

natural sympathy• Whole / holistic

appreciation

Cons• Bias• Causation contrived• Difficult to refute• Must deal with fiction

The dimensional perspective:

1. Focuses on individual psychological dimensions that are universal, measurable, and graded (cognition and temperament)

2. Has an underlying conceptual triad of potential, provocation, and response

3. Applies to psychiatric conditions that arise from who a person is

4. Suggests guidance as the treatment goal

Quantitative dimensions

• Intelligence (mental retardation / ASD)– Defining a psychological disposition– Is a potential to change

• Personality type (personality disorders)

Eysenck circle

Eysenck HJ (1970)

The behavior perspective:

1. Seeks to identify and explain disorders of individual choice

2. Has an underlying conceptual triad of choice, physiologic drive, and conditioned learning

3. Applies to psychiatric conditions characterized by what a person does

4. Suggests interrupting as the treatment goal,prompting choice of recovery.

• Dependence / abuse• Anorexia / bulimia nervosa

Stage

• Precomtemplative stage– No thoughts of changing behavior

• Contemplative stage– Considering change but they were not ready to

accept the implications for the way of life• Action stage– Ready to act against the behavior

Therapies considered

Treatments of drive• Satisfaction replacements

– Methadone, nicotine patch

• Drive reduction– Medroxyprogesterone

acetate

• Response punishment– Disulfiram [antabuse]

• Reinforcement blockage– Naltrexone

• Harm reduction

Treatments of social learning• Redirection with

psychotherapy to better consequences

• Rewards for appropriate choices and responses(token economies)

• Social restructuring and rehabilitation(family therapy)

The disease perspective:

1. At its essence is about an abnormality in the structure or function of the brain expressed in the development of a syndrome

2. Has an underlying conceptual triad of clinical syndrome, pathology, and etiology

3. Applies to psychiatric conditions that a patient has

4. Suggest curing as the treatment goal

Disease reasoning

• Documenting a patient’s clinical history• Conducting a physical and psychological exam• Observing the progress of symptoms over time You just assess how closely the pt resembles other pts• Identifying symptoms• Linking the symptoms to a pathology• Arriving at a cause

Strengths and weakness

• Strengths– Familiar to most students of medicine– Produces testable models– Encourages research– Supportive of collaborative efforts btw physicians and basic

scientists• Weakness

– May neglect to consider the individual and his or her unique vulnerabilities to distress

– A disease model can be endlessly refined – Provokes the temptation to presume a brain source for all

matters of mental distress

• Relatively-known neuropathologies– Dementia– Delirium – …

• “Original madness” or “Psychosis”– Manic-depression– Schizophrenia

Perspectives of PsychiatryPerspective Triad What a

patient…Treatment

goal

Disease Clinical Syndrome Pathological ProcessEtiology

Has Curing

Dimensional PotentialsProvocationsResponses

Is Guidance

Behavior ChoicePhysiological DriveConditioned Learning

Does Interrupting

Life story SettingSequenceOutcome

Encounters Rescripting

All Medications Are Toxic

All Guidance Are Paternalistic

All Stopping Is Stigmatizing

All Interpretations Are Hostile

References• McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding

personality structure in the clinical process, Guilford Press.• Callard F, Bracken P, David AS, Sartorius N. Has psychiatric diagnosis

labelled rather than enabled patients? BMJ. 2013 Jul 25;347:f4312.• 江川 , 純 , 遠藤 , 太郎 , 染矢 , 俊幸 , 下田 , 和孝 , 塩入 , 俊樹 , 山田 , 尚登 , & 高橋 , 三郎 . (2010). 精神科疾患の診断をめぐる諸問題　精神科医327名のアンケート調査から . 精神医学 , 52(9), 891-898.

• van Os J, Delespaul P, Wigman J, Myin-Germeys I, Wichers M. Beyond DSM andICD: introducing "precision diagnosis" for psychiatry using momentary assessment technology. World Psychiatry. 2013 Jun;12(2):113-7.

• Peters ME, Taylor J, Lyketsos CG, Chisolm MS. Beyond the DSM: the perspectives of psychiatry approach to patients. Prim Care Companion CNS Disord. 2012;14(1).